Clinical Denials Clinician

Clinical Denials Clinician

Tenet Global Business Center, Inc.
Metro Manila / NCR
2-5 years
Not Specified

Job Description

Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step! The Clinical Denials Clinician for the Appellate Solution is responsible for:
a) Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
b) Preparing and documenting appeal based on industry accepted criteria.
Responsibilities and Duties
• Performs retrospective (post-discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.
• Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual®, as evidenced by Inter-rater reliability studies and other QA audits.
• Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office.
• Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.
• Additional responsibilities:
o Serves as a resource to non-clinical personnel
o Provides CDC leadership with sound solutions related to process improvement
o Assist in development of policy and procedures as business needs dictate
o Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
Knowledge, Skills, and Abilities
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Demonstrates proficiency in the application of medical necessity criteria, currently InterQual®
• Possesses excellent written, verbal and professional letter writing skills
• Critical thinker, able to make decisions regarding medical necessity independently
• Ability to interact intelligently and professionally with other clinical and non-clinical partners
• Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
• Ability to multi-task
• Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
• Ability to conduct research regarding off-label use of medications

Tenet Healthcare is a healthcare services company headquartered in Dallas, Texas. We operate 65 hospitals and approximately 500 other healthcare facilities across the US. The company is listed in the NYSE.

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